GREATER MANCHESTER FIRE AND RESCUE SERVICE GREATER MANCHESTER FIRE AND RESCUE SERVICE The Cube Incident Report and Key Observations regarding the fre which occurred on 15 November 2019 GREATER MANCHESTER FIRE AND RESCUE SERVICE 2 GREATER MANCHESTER FIRE AND RESCUE SERVICE CONTENTS 5 Foreword 6 Introduction 8 Scope 9 Key Observations 10 Executive Summary 13 Background 17 GMFRS Preparedness 21 The Cube Building 32 Summary Incident Timeline 45 Post Incident 46 Operational Response to The Cube 57 Firefghting 60 Evacuation 63 Welfare 64 Afterword 66 Key Observations and Actions Warning: this document contains images that some readers may fnd distressing. 3 GREATER MANCHESTER FIRE AND RESCUE SERVICE Image 1: The Cube – 15th November 2019 4 GREATER MANCHESTER FIRE AND RESCUE SERVICE FOREWORD On 15 November 2019 a fre broke out at The Cube, student accommodation in Bolton town centre. The speed with which the fre took hold and the devastating impact it had on the building was truly shocking. We would like to introduce this report by expressing our appreciation for the actions of all those who responded to the fre. The incident demonstrated the great courage and effective decision making of our frefghters and offcers in the face of extremely testing circumstances. As well as our own colleagues, residents of The Cube displayed courage, integrity and community spirit as they found themselves involved in a major incident. Partners from North West Fire Control, Greater Manchester Police, North West Ambulance Service, Bolton Council, and the University of Bolton also responded with courage and commitment to support operational frefghting, strategic decision making, and the evacuation and relocation of residents. The incident highlights the risks within the built environment and the national pattern of buildings failing in fres. To deal with this threat, Greater Manchester Fire and Rescue Service implemented a new procedure at the incident, a procedure that requires more resources be sent to a fre than was previously planned or budgeted for. Whilst we will offer learning and areas of refection within this report, we are very proud that the overall response was a clear example of the high standards and professionalism that exist across Greater Manchester. Thanks to the quick and effective decision-making of frefghters and offcers on the night, and the actions of many of the students themselves, there was thankfully no loss of life. Baroness Beverley Hughes Jim Wallace Deputy Mayor for Policing and Crime Chief Fire Offcer Greater Manchester Combined Authority Greater Manchester Fire and Rescue Service 5 GREATER MANCHESTER FIRE AND RESCUE SERVICE INTRODUCTION 1. Greater Manchester Fire and Rescue Service (GMFRS) is one of the largest Fire and Rescue Services (FRS) in the United Kingdom with 41 fre stations, 35 of which are crewed on a wholetime basis. GMFRS covers an area of approximately 500 square miles and serves a culturally diverse population of 2.8 million people. 2. From modern inner-city developments to traditional mill towns, to areas of moorland and open countryside, Greater Manchester is made up of ten very different districts; Bolton, Bury, Manchester, Oldham, Rochdale, Salford, Stockport, Tameside, Trafford and Wigan. The FRS is part of the Greater Manchester Combined Authority (GMCA)1. 3. On 15 November 2019 a fre occurred at ‘The Cube’, a multi-occupied residential building in Bolton, Greater Manchester. Rapid and unexpected fre spread was evident from the outset, severely affecting the building which featured a High Pressure Laminate (HPL) external wall cladding system. 4. A subsequent detailed investigation has determined a discarded cigarette as the most probable cause of fre. 5. Despite life being evidently at risk from the very intense and unpredictable fre, no serious injuries were reported and all 217 residents were accounted for. 6. The fre did, however, severely disrupt the studies and lives of a large number of residents, predominantly students at the University of Bolton. The loss of work, personal belongings and documents, and in the case of overseas students, passports and visa documentation added to the immediate impact of being involved in a very serious fre. 1Greater Manchester Combined Authority: greatermanchester-ca.gov.uk 6 GREATER MANCHESTER FIRE AND RESCUE SERVICE 7. Since 2018, GMFRS, the Greater Manchester High Rise Task Force (GMHRTF) and industry experts had been warning that HPL external wall systems, made of wood-based layers impregnated with resin and pressed together under high temperatures, posed a signifcant risk in relation to external fre spread. 8. The purpose of this report is to provide an outline of the fre at The Cube and allow GMFRS to offer constructive learning outcomes identifed from an analysis of its own operational response to the incident and the wider organisational support mechanisms. GMFRS feels duty bound to provide this summary to all interested parties and stakeholders, including residents of The Cube and the wider public. 9. This report also serves as an opportunity specifcally for FRSs and other responders to refect on operational preparedness and the provision of service delivery, and where identifed as necessary to implement or adapt GMFRS’s own refection and analysis into any local arrangements. 10. The fre at The Cube was not the frst where a building has been seen to ‘fail’ under fre conditions, in contrast with traditional knowledge and understanding of fre behaviour in the built environment. Such incidents have presented challenges to members of the public, FRSs and other key responding and responsible agencies. References to a number of these incidents are included within this report. 11. In presenting this report, GMFRS appreciates that not all readers will be familiar with FRS operational procedures, equipment and terminology. Therefore, abbreviations will be explained within the report and footnotes used to explain terminology and concepts. 7 GREATER MANCHESTER FIRE AND RESCUE SERVICE SCOPE 12. This report is produced following an internal Strategic Incident Review (SIR) and Fire Investigation (FI) carried out by GMFRS following the fre at The Cube. 13. The report will offer background information on the building and GMFRS’s pre-planning and collation of operational risk information. 14. The report will offer facts and a timeline relating to the mobilisation of resources via North West Fire Control (NWFC)2. 15. The report will detail GMFRS’s operational and strategic response to the incident. It will detail the high-level organisational learning that has been identifed thus far, and aims to share this openly for the beneft of other FRSs and stakeholders. Out of Scope 16. This report will not detail the fndings or conclusions of GMFRS’s FI Report3; specifcally it will not offer an explanation of the means or mechanisms of fre spread, nor will it consider compliance with the Regulatory Reform (Fire Safety) Order 2005 or other regulations. 17. This report will not therefore, consider the materials used within the external wall construction and what if any role materials played in the development and spread of fre. 18. The report does not aim to offer detail on multi-agency partners’ or other organisations’ responses to the fre although some information is referenced where applicable. 2North West Fire Control is a public sector company set up exclusively by Fire and Rescue Services in the North West to jointly handle all 999 emergency calls and be responsible for mobilising frefghters and fre engines to incidents in Greater Manchester, Cumbria, Lancashire and Cheshire. 3GMFRS’s Fire Investigation Report into the fre at The Cube will be published shortly following release of this report. 8 GREATER MANCHESTER FIRE AND RESCUE SERVICE Information Sources 19. The information offered in the report has been obtained from witness accounts from GMFRS personnel, and photographic evidence including such images obtained from open source material within the public domain. 20.Data sources used to produce this report are primarily from analysis of GMFRS electronic records, data supplied by NWFC’s mobilising system, contemporaneous notes and decision logs and witness accounts including the debriefng of individuals and teams who attended the scene or supported the incident remotely. KEY OBSERVATIONS 21. Specifcally for readers of this report, a number of Key Observations are highlighted throughout where GMFRS feel there is value in sharing areas of refection. These Key Observations are refective of learning further validated by positive application prior, during and post the fre at The Cube, but also refection on where GMFRS itself will seek improvement. 22. The report will offer at its close, a summary of actions identifed for GMFRS based on the Key Observations offered within this report and gathered as part of GMFRS’s own investigations and analysis into the fre. 23. Where applicable, Key Observations and associated actions will be linked to other report recommendations where GMFRS feel this highlights an opportunity for increased learning. It is apparent that a number of observations in respect of The Cube are not new, and hence, there are existing recommendations in place which remain valid. Where applicable these have been openly and directly replicated or referenced for the purpose of enforcing prior opportunities for learning and improvement previously and / or independently identifed. 9 GREATER MANCHESTER FIRE AND RESCUE SERVICE EXECUTIVE SUMMARY 24. As with all emergency incidents, the importance of extracting any learning is paramount to allow the cyclical approach of review and improvement. Following an internal SIR of The Cube incident, work is on-going within GMFRS to identify further learning to support internal improvement. 25. At 20:29 hours on Friday 15 November 2019 NWFC received a 999 call from a mobile phone in which the caller reported a fre at ‘The Cube 85- 93 Bradshawgate, Bolton’. 26. The incident was subsequently declared a Major Incident3 and at its peak had an attendance of 27 fre engines and special appliances4.